MEDICARE: MS. AUDREY FARRELL LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	227.013694	IL

General Provider Information

NPI Number	:	1437428166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUDREY FARRELL LMT

Provider Business Mailing Address
First Line	:	1931 W EVERGREEN AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-6958
Country	:	US
Telephone Number	:	312-802-0493
Fax Number	:	773-227-9160

Provider Business Practice Location Address
First Line	:	1834 W NORTH AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-1312
Country	:	US
Telephone Number	:	773-227-9150
Fax Number	:	773-227-9160

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2011
Last Update Date	:	12/27/2011

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